Treatment Of Service Members Research Articles

TBICoE approach to concussion rehabilitation in service members and veterans.

Concussion, also known as mild traumatic brain injury (mTBI), is a condition with unique ties to military service. Service members (SMs) are inherently at a higher risk for concussive injuries due to the intense physical training environment and combat operational tempo required to serve. The Traumatic Brain Injury Center of Excellence (TBICoE) is the US Department of Defense authority on this condition and provides a thorough approach to management of concussion and associated symptom sequela. This article seeks to review the TBICoE approach to the management and rehabilitation of military SMs with mTBI, and highlight resources available to military medical providers. The authors reviewed evidence and TBICoE resources to provide this comprehensive overview of the TBICoE approach to management and rehabilitation of concussion in military SMs. A progressive return to activity protocol in conjunction with symptom-guided management of common post-concussive sequelae, including headache, vestibular and oculomotor issues, sleep dysfunction, cognitive rehabilitation, and behavioral health comorbidities are essential for concussion management in the acute, post-acute and chronic phases of injury. The TBICoE approach to the rehabilitation of military SMs is comprehensive, and includes initial management with a stepwise return to duty protocol and an objective return to duty screening. The mainstays of treatment for SMs with post-acute and chronic post-concussion symptoms are headache management, vestibular and oculomotor rehabilitation, sleep interventions, cognitive rehabilitation, and early intervention for behavioral health comorbidities. These evidence-based strategies may be applied in the treatment of SMs in the US and internationally.

Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions.

Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness.Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge.Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge.Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms

BackgroundThe present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day.MethodsMale active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models.ResultsImprovements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%.ConclusionsThe low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans.Trial registrationAustralian Clinical Trials Registry ACTRN12616000956404.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population

ObjectivesTo evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education. DesignLongitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit. SettingThree military treatment facilities. ParticipantsStudy participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded. InterventionNot applicable. Main Outcome MeasuresActivity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury. ResultsReceipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time. ConclusionsConcussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider’s use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Psychometric Properties of Four Commonly Used Suicide Risk Assessment Measures: Applicability to Military Treatment Settings

Clinicians working in U.S. Department of Defense behavioral health settings rely on standardized suicide risk assessment measures to guide their treatment of service members. Most of the measures used were developed, normed, and validated for use with civilians. Although there is reason to believe such measures will perform similarly in civilian and military treatment settings, that assumption has rarely been confirmed empirically. The purpose of the current study was to examine data from a large assessment study to confirm the reliability and validity of 4 widely used suicide risk assessment measures for military personnel. The risk assessment measures were (a) Columbia-Suicide Severity Rating Scale; (b) Self-Harm Behavior Questionnaire; (c) Suicidal Behaviors Questionnaire—Revised; and (d) Beck Scale for Suicide Ideation. Items from the Military Suicide Research Consortium’s Common Data Elements were used to examine convergent validity. Data from 1,044 military service members at risk for suicide who completed baseline assessments were used in the current analyses. Small differences were found across the measures, but overall performance was acceptable and all are considered valid and reliable to use when assessing active duty U.S. military personnel.

Dual tasking to optimize performance for the tactical athlete

This session with cover aspects of the DoD's Intrepid Spirit (IS) model for caring for service members with symptoms of traumatic brain injury (TBI) and comorbidities and taking care further with interdisciplinary management of the high-level functioning tactical athlete. Traumatic brain injury and concussion are common injuries among service members and athletes. As more research is completed on concussion, consequences of this injury have become better understood, but much is still left unknown, to include proper treatment for high performance tactical athletes and service members. This lecture will discuss interdisciplinary treatment for high-level performance needs with emphasis on utilization of dual tasking. This session will describe the IS mission and programs available through the Warrior Recovery Center at Fort Carson then further expand upon specialized co-treatments between Speech-Language Pathology (SLP) and Physical Therapy (PT) to push high-level patients to a higher standard. These interventions include aggressive dual-task demands with balance, exertional, and endurance tasks combined with challenges of working memory, delayed recall, visual tracking, language fluency, visual reasoning, and executive functions in English and the service member's secondary language. A case report will be provided to offer example interventions as well as improvements throughout treatment for service members who participated in this advanced intervention.

Rabies, Readiness, and Role 1 Medical Care

As medics and doctors prepare for deployment to a combat zone, there are countless specified and implied tasks needed to prepare the medical support of an Infantry unit in theater. Appropriately, units spend the lion share of their efforts in trauma training and medical readiness (vaccinations, medication prescriptions, eye glasses, etc.) while ensuring that the sets, kits, and outfits are all fully stocked with the required items needed to execute the mission. Unfortunately, this training and preparation included little on the major challenges units currently face from rabies. With the unfortunate recent death of a soldier from rabies, medical personnel were required to become experts in animal control, the prevention of animal bites and scratches, and the most appropriate treatment of service members with potential exposure to rabid animals. This article will discuss the challenges of rabies management in Afghanistan, appropriate provider and unit preparation to minimize risk of developing rabies, the need for establishment of an animal control team and prerequisite training of soldiers, leaders, and medics before and during deployment. Finally, we will review published guidelines for treating individuals exposed to rabies with a discussion of our units experience with postexposure prophylaxis.

Eating Disorder in a Young Active Duty Male

Eating disorders can have atypical presentations, be challenging to diagnose, and often result in treatment delay, as illustrated here. Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, and is ten times more common in females. Studies show increased prevalence over the past decade, with similar prevalence in young military members and civilians. Risk factors include dieting, gender preference, life-altering events, and history of a psychiatric condition. Relatively little research has focused on eating disorders among military males, but factors unique to this group include rigid weight standards, mandatory semiannual personal fitness assessments, and extended deployments. Bulimia and other eating disorders can have subtle or atypical presentations and are often overlooked in males. Other diagnostic obstacles include career concerns and stigma avoidance, along with provider time constraints, inexperience, or discomfort with the issue. Serious medical complications of bulimia are uncommon, but delayed diagnosis can lead to hospitalization and significant morbidity. This case emphasizes the importance of a thorough history and wide differential when faced with an unusual presentation. Recognizing risk factors and incorporating simple screening tools can aid the timely identification and treatment of service members with disordered eating before unit and mission effectiveness are compromised.

Helping Children With the Psychosocial Effects of a Parent's Deployment: Integrating Today's Needs With Lessons Learned From the Vietnam War

Social workers who treat children of deployed servicemembers may feel poorly prepared to work competently with military families and will benefit from understanding the immediate and long-term effects of parental deployment upon children. This review consolidates a substantial, shifting knowledge base and establishes a coherent theoretical framework for social workers to learn about the effects of war-specific deployment cycles for servicemembers, and the relationship among family members' and children's experiences with deployment separation. The author considers important lessons learned during the Vietnam War and the unique experiences specific to current wars. This article compares the Vietnam War and the more recent wars' characteristics of military deployment, demographic characteristics of service members, servicemembers' family characteristics, and research findings about the psychosocial effects of deployment on children. A case vignette is presented to clarify how an understanding of deployment and reintegration is necessary for the treatment of servicemembers, families, and children by social workers.

Continuum of care: Military health care providers and the traumatic brain injured service members

This article will address and describe the military continuum of care and its implications for the health care providers intimately involved in the treatment of service members who sustain traumatic brain injuries (TBI). Clinical Practice Guidelines have been created and distributed for treatment of TBI sustained by service members in both the deployed setting and in the continental United States (CONUS). The military has established specific levels of care each with specific purpose in the treatment continuum that extends from the battlefield to the most advanced military treatment facility (MTF). The health care providers who care for this particular patient population can also face unique opportunities, challenges and rewards.

Validating the assessment of Glucose-6-Phosphate dehydrogenase (G6PD).

1. Charles Asowata Major, MS MT(AMT) CLS(NCA) 2. Emily Fincher, MS MT(ASCP) 3. Vernon Koziatek, BS CLS(NCA) 1. are of the Dwight D Eisenhower Army Medical Center, Fort Gordon GA 1. Lester Pretlow, PhD CLS(C) NRCC(CC)[⇑][1] 1. is of the Department of Biomedical and Radiological Technologies, Medical College of Georgia, Augusta GA 1. Address for correspondence: Lester G Pretlow PhD CLS(C) NRCC(CC), Assistant Professor, Department of Biomedical and Radiological Technologies, AL-106, Medical College of Georgia, Augusta GA 30912-0500. (706) 721-7629, (706) 721-7631 (fax). lpretlow{at}mail.mcg.edu Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme of clinical significance to the Armed Services. The ability to determine accurate erythrocyte concentrations of G6PD is imperative for the prophylaxis and treatment of service members against a variety of opportunistic hemolytic infectious diseases, such as malaria, which might be encountered during deployment.1 G6PD catalyzes the first oxidation reaction in the pentose phosphate shunt, in which glucose-6-phosphate is dehydrogenated to 6-phosphogluconolactone with the concurrent reduction of nicotinamide adenine dinucleotide phosphate (NADP).2 This reaction is the only source of the reduced form of NADP, NADPH, which provides the reducing power to change oxidized-glutathione into reduced-glutathione.3 Reduced glutathione acts as a reducing agent against oxidative insults to the erythrocyte. G6PD deficiency is expressed when individuals with decreased reduced-glutathione concentrations are administered oxidant drugs such as quinine, analgesics, and sulfonamides.3 The decrease in reduced-glutathione leads to the inability of erythrocytes of these individuals to endure the oxidative assault of these drugs. As a consequence, erythrocytes lose their structural integrity, resulting in hemolytic anemia that can be moderate to life threatening. G6PD deficiency is the most widely distributed enzyme defect of erythrocytes in humans, therefore, it is important to screen all service members for the enzyme deficiency before they are prophylaxed in preparation for deployment.4 This potential for drug induced hemolytic complications demands screening and for that reason, the analytical procedures for assessing G6PD concentrations must be rigorously validated to ensure the best quantitative determinations.5 Most methods for the analysis of G6PD are based on the assessment of… ABBREVIATIONS: CAP = College of American Pathologists; EA = allowable error; G6PD = Glucose-6-phosphate dehydrogenase; MDC = medical decision chart; MDL = medical decision level; NADP = nicotinamide adenine dinucleotide phosphate; RE = random error; SD = standard deviation; SE = systemic error. [1]: #corresp-1